Provider Demographics
NPI:1487027694
Name:FUNCTIONAL HEALTH ACUPUNCTURE AND MASSAGE THERAPY PLLC
Entity Type:Organization
Organization Name:FUNCTIONAL HEALTH ACUPUNCTURE AND MASSAGE THERAPY PLLC
Other - Org Name:FUNCTIONAL HEALTH ACUPUNCTURE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:MCGILVERY
Authorized Official - Suffix:
Authorized Official - Credentials:L AC, LMT
Authorized Official - Phone:917-868-2480
Mailing Address - Street 1:3801 23RD AVE
Mailing Address - Street 2:UNIT 100
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11105-1532
Mailing Address - Country:US
Mailing Address - Phone:917-868-2480
Mailing Address - Fax:
Practice Address - Street 1:3801 23RD AVE
Practice Address - Street 2:UNIT 100
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11105-1532
Practice Address - Country:US
Practice Address - Phone:917-868-2480
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-10
Last Update Date:2015-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005637171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty